Words are amazingly precise
A patient in her 30s was defending her mother as she heavily blamed herself for her ongoing failure to function. She described how her mother was sometimes very supportive, but had been critical and harsh when told of the patient’s plan to attend her friend’s bachelorette party. I listened for a while to multiple instances of both kinds of response and ventured softly, “I am sure she’s a nice lady, but she’s also a bit impossible.” My patient laughed, and we both knew those few words had captured the situation and her true feelings.
In both psychology and psychiatry, talk has long suffered from being mislabeled as fuzzy or imprecise. Subjective truth expressed in words has been tarnished for being unquantifiable and unscientific. To the contrary, talk is by far the most powerful and specific tool we have for accurately capturing experience and thereby activating the precise handful of neurons that embody our patients’ most troubling patterns of response.
Why do we need to activate those neurons? The neurophysiology of threat responses tells us that activation of specific neural networks embodying a maladaptive response is the first of two requirements for change. Whether the change process is Extinction (where the perception of danger remains unchanged but the response is inhibited) or Memory Reconsolidation, (where the perception of danger is permanently modified) those neurons must first be in an active state. The other requirement is for more or less simultaneous exposure to new and surprising information. In the interaction with my patient, our verbal exchange was the catalyst for both requirements to be met. Here is my hypothesis:
The context of my patient’s comments was that she felt she should telephone her mother and was dreading it. She was disappointed not to receive mother’s approval but could not allow herself to be critical of her mother for not giving it. Instead, it had to be her fault. But she understood that going to the party was entirely normal and appropriate. She knew she was right, but an accurate assignment of responsibility for mom’s disapproval was completely off limits.
This re-evoked a longstanding and unresolvable dilemma, the cause of her hopelessness and inability to function. She could not risk a break with mother, but wrongfully blaming herself for conflict between the two was causing her to feel depressed and lose motivation to do anything constructive.
At the moment of our exchange, all the neuronal circuits involved in her unsuccessful response to the situation were active with full affect (feeling + bodily changes). Affect is our clinical indicator that limbic components essential for triggering maladaptive responses were engaged as well. That completed the first requirement for change. What was still needed was the second requirement, surprising new information, and my words supplied that. Those thirteen words slipped by her censors and legitimized a correct attribution of the source of her trouble. Her mother was, indeed, impossible to satisfy.
A bit more context is warranted from a developmental viewpoint. The definition I use for adulthood is “a subjective sense of full ownership of one’s own life.” In childhood, the parents are proprietary and ultimately responsible. Regardless of chronological age, the emotional job of adolescence is letting go of dependence on parental guardianship and accepting full responsibility. That’s hard for everyone, but especially hard when the parents have not given their full blessing to the process. For my patient, the task of accepting full responsibility for herself had been delayed, waiting for her mother’s approval, which would never be fully granted. That is why the relationship was so fraught and intense and why seeking maternal acceptance and support was so important for her.
Ultimately the answer is going to be partially disengaging from mother, grieving for the failure to receive consistent support, and accepting limits in the bond between them. This will be a hard process, but necessary for my patient’s ultimate empowerment, liberation, and transition into psychological adulthood.
The “take homes”
So what are the lessons to be learned from this exchange?
Activation of the maladaptive response, with affect, is our clinical indication that the conditions are right for change to happen.
Simultaneous exposure to new information that can update the old is the other requirement for change, the “antidote.”
Verbal exploration is an exceedingly powerful and precise way to activate old responses. A good way to capture the essence of this process is the idea of seeking “accurate empathy,” a term coined by Carl Rogers. There are other ways to activate responses such as two-chair exercises, suggesting behavior change, or maintaining an intense therapeutic relationship over time, but words are the most flexible and “articulate.”
And words are good for the antidote as well. In order to expose a patient to relevant and precise new information, verbal exchange of the affect-laden material may be the most powerful and basic means available to clinicians.
These tools should be in the repertoire of every mental health practitioner. Available to all of us, they are the most flexible, the most precise, and often the best ways to bring about lasting change in Entrenched Maladaptive Patterns (EMPs).
Jeffery Smith MD
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